Infectious Aortitis

Abstract

SummaryAortitis is broadly divided into infectious and non-infectious etiologies, each with distinct treatment implications. We present the case of a patient who sustained a type A aortic dissection during urgent coronary angiography for acute coronary syndrome. Clinical findings and events during the procedure raised suspicion for an underlying vascular disorder; however, the diagnosis of staphylococcal aortitis was not made until pathological examination of resected tissue. Clues to the diagnosis of infectious aortitis noted throughout the patient's clinical course are detailed as are potential consequences of diagnostic delays and treatment decisions, underscoring the difficulties in recognizing and managing the condition. In addition, we describe a previously unreported complication of cardiac catheterization in the setting of an infectious aortopathy. (Int Heart J 2016; 57: 645-648) Key words: Aortic dissection, Coronary angiography, Iatrogenic disease D ifficulties in diagnosing aortitis are compounded by the importance of differentiating between its infectious and non-infectious etiologies given their markedly divergent treatment implications.1) We describe a patient who underwent urgent coronary angiography that was complicated by iatrogenic type A aortic dissection (iAAD) requiring surgical intervention. Staphylococcus aureus aortitis was diagnosed on pathological examination. We emphasize the need for a high index of suspicion to accurately diagnose infectious aortitis (IA), review pitfalls in its recognition and management, and describe its previously unreported association and postulated contribution to iAAD during coronary angiography. Case ReportAn 83-year-old woman presented to hospital with polyarthralgia, muscle stiffness, and generalized weakness following a fall. She denied fevers or rigors, chest discomfort, or jaw claudication. Her medical history included stable angina with previous coronary angioplasty, hypertension, dyslipidemia, and hypothyroidism. Her exam was notable for bradycardia at 52 bpm, an oxygen saturation of 93% on 2 L/minute of oxygen via nasal cannula, mild jugular venous distention with unremarkable heart sounds and lung fields, and no peripheral edema. Investigations revealed neutrophilic leukocytosis (16.7 × 10 9 /L), acute kidney injury, and troponin I of 0.66 μg/L. Her erythrocyte sedimentation rate was elevated at 100 mm/h as was her C-reactive protein at > 190 mg/L. Chest x-ray demonstrated a left lower lobe consolidation. Cefuroxime and doxycycline were initiated and the patient was admitted to hospital with a diagnosis of community-acquired pneumonia. Urine cultures grew methicillin-sensitive S. aureus (MSSA), prompting the medical team to change her antibiotics to intravenous ceftriaxone, but repeated blood cultures were negative.On her third day in hospital, the patient developed severe retrosternal chest pain and diaphoresis. Her ECG demonstrated new inferior ST-elevation with reciprocal ST-changes and her troponin I rose to 4.18 μg/L, prompting urgent coronar...

Case of ruptured Staphylococcus aureusaortitis: presentation and management

“…In previous publications, SA aortitis has been reported 2 5. Our observation adds to this pool of diagnosis and treatment of the SA aortitis, highlighting the importance of early diagnosis and surgical management.…”

A Rare Case of Rush Progression of Purulent Pericarditis by <i>Escherichia coli</i> in a Patient with Malignant Lymphoma

“…Although the major causes of bacterial pericarditis are such as Staphylococcus, 5) Streptococcus, Haemophilus, and Mycobacterium tuberculosis, 6) in this case, purulent pericarditis was caused PURULENT PERICARDITIS BY Escherichia coli by very uncommon gram-negative bacillus, E. coli. The unexpected causative bacteria of E. coli and sudden clinical changes without a premonitory severe symptom were peculiarity of this case.…”

A review on the deeper understanding of inflammation and infection of the thoracic aorta

“…Disadvantages of MRI include the fact that it is not always available and its unsuitability for patients with implanted devices or who are critically unwell. 8 Recent studies have found 3D-black-blood MRI is an effective and radiation-free alternative to cross sectional CT imaging for the diagnosis of thoracic large vessel vasculitis, making it a useful modality for investigating non-infectious aortitis. 19,20 Both MRI and multi-slice CT imaging are useful in defining the extent of the disease and for planning surgical intervention.…”

“…Despite having been the investigation of choice in the past, angiography is invasive and poses the risk of causing the rupture of the aortic wall which can be very fragile when inflamed. 8 As such, it remains useful only in situations where aortitis or a mycotic aneurysm cannot be excluded otherwise. 11 Similarly, ultrasound scanning (US) is not a commonly used modality for diagnosing aortitis, but abdominal or transthoracic US can show circumferential thickening of the aortic wall and can be useful in identifying and assessing aneurysms in the ascending thoracic aorta.…”

“…This can be difficult due to the nonspecific signs and symptoms and differing clinical presentations. It should be suspected in patients over the age of 50, with a history of atherosclerosis or aneurysmal disease if they present with thoracic/back pain, nausea, vomiting and fever 8 . Nonspecific symptoms and results include fever (75%), thoracic and back pain (60%), abdominal pain (20%), leucocytosis, neutrophilia and elevated inflammatory markers.…”